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Case ReportTreatment of Necrotic Calcified Tooth Using
IntentionalReplantation Procedure
Nima Moradi Majd,1 Armita Arvin,2 Alireza Darvish,1
Sareh Aflaki,1 and Hamed Homayouni1
1 Department of Endodontics, Dental School, Qazvin University of
Medical Sciences, Qazvin 34157-59811, Iran2Department of
Endodontics, Dental School, Yazd University of Medical Sciences,
Yazd 8914881167, Iran
Correspondence should be addressed to Armita Arvin;
[email protected]
Received 3 January 2014; Accepted 22 January 2014; Published 4
March 2014
Academic Editors: Y.-C. Hung and J. J. Segura-Egea
Copyright © 2014 Nima Moradi Majd et al. This is an open access
article distributed under the Creative Commons AttributionLicense,
which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properlycited.
Introduction. If the teeth are impacted by a chronic irritant,
the pulp space possibly will undergo calcific changes that may
impedeaccess opening during root canal treatment. In such cases
that conventional endodontic treatment is impossible or
impractical,intentional replantation may be considered as a last
solution to preserve the tooth.Methods. After failing to perform
conventionalroot canal therapy for a necrotic calcified right
mandibular second premolar, the tooth was gently extracted. The
root apex wasresected and the root end cavity was prepared and
filled with calcium enriched mixture (CEM) cement. Then, the
extracted toothwas replanted in its original position. Results.
After a year the tooth was asymptomatic, and the size of periapical
radiolucency wasremarkably reduced and no clinical sign of
ankylosis was observed. Conclusion. Intentional replantation of the
necrotic calcifiedteeth could be considered as an alternative to
teeth extraction, especially for the single-rooted teeth and when
nonsurgical andsurgical endodontic procedures seem impossible.
1. Introduction
The root canal systems of the teeth usually remain patent
andaccessible, but if they are impacted by a chronic irritant,
thepulp space possibly will undergo calcific changes that mayimpede
access opening during root canal treatment [1].
Although pulp space of this kind of teeth sounds com-pletely
obliterated in preoperative radiographs, this spacehas adequate
room to allow passage of millions of microor-ganisms [2].
Therefore, a calcified tooth with pulp necrosisinevitably leads to
induction of apical periodontitis [1].
The first option for treatment of a calcified necrotic toothis
the conventional root canal therapy [3], but teeth withsevere
calcification may present challenges with locating andnegotiating
root canals.The other options beside nonsurgicalendodontic
treatment include root resection using a surgicalmethod [4] and
intentional extraction and replantation [5].
Intentional replantation procedure is usually consideredas a
last resort [6], but in some cases that conventionalendodontic
treatment or apical surgery is impossible or
impractical, intentional replantation may be considered as
asolution to preserve the tooth [6].
The present case report describes a successful treatmentof a
calcified necrotic mandibular second premolar usingintentional
replantation procedure.
2. Case Presentation
A 44-year-old female with no contributing medical historywas
referred to the Endodontic Department of Qazvin schoolof Dentistry.
She stated that her right mandibular secondpremolar hurt when she
chews. After clinical examination,moderate tooth attrition on the
occlusal surface of thetooth was observed. The tooth was moderately
sensitive topercussion, but neither sinus tract nor periodontal
pocketwas detected. Radiographic examination revealed that thepulp
space has been seriously obliterated. In addition, peri-apical
radiolucency was observed at the apex of the rightmandibular second
premolar (Figure 1).
The tooth was examined by electric pulp test (EPT) usingthe
Element Diagnostic Unit (SybronEndo, Glendora, CA)
Hindawi Publishing CorporationCase Reports in DentistryVolume
2014, Article ID 793892, 5
pageshttp://dx.doi.org/10.1155/2014/793892
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2 Case Reports in Dentistry
Figure 1: Preoperative radiograph; the pulp space of the
rightsecond mandibular premolar has been seriously obliterated
andperiapical radiolucency is observed at the apex of the
tooth.
Figure 2: In order to find root canal’s orifice, some
workingradiographs were taken, but root canal negotiation was
impossible.
and cold test (Roeko Endo-Frost; Roeko, Langenau, Germa-ny).
The presence of the periapical radiolucency and tooth’snegative
responses to EPT and cold test convinced us thatthe right
mandibular second premolar is a necrotic tooth thatneeds to undergo
conventional root canal therapy.
The inferior alveolar nerve block (IANB) was carried outusing a
cartridge of lidocaine (2% lidocaine with 1/80000epinephrine;
Darupakhsh, Tehran, Iran); after proper iso-lation, an endodontic
postdoctoral student attempted toprepare an endodontic access at
lower right second premolarwith a round bur, but at the normal
anatomical orifice level,no sign of orifice was found. He continued
trying to find theroot canal’s opening (Figure 2), but when he was
attemptingto negotiate the calcified canal, a perforation was
createdon the distal root surface 1mm below the alveolar crest.The
perforation was sealed using calcium enriched mixture(CEM) cement
(BioniqueDent, Tehran, Iran) (Figure 3), andthe access cavity was
sealed with Cavit (coltosol, AriaDent,Tehran, Iran). The next
treatment’s options (apicoectomy,intentional replantation,
extraction, and implant replace-ment) and their risks and benefits
were described to thepatient; we explained that apicoectomy is more
predictablethan intentional replantation, but there is danger of
damagingcontents of mental foramen; but the patient was going
toconsult her dentist about the treatment plan.
On the next day, the patient called the endodonticdepartment and
told us she consulted with her dentist
Figure 3: Calcium enriched mixture cement was used to seal
theperforation.
and decided to do the intentional replantation. Thus, wearranged
an appointment and restored the access cavity ofthe tooth number 29
using composite restoration. A writteninformed consent was obtained
and shewas scheduled for theintentional replantation.
At the patient’s return, antisepsis was carried out using0.2%
chlorhexidine gluconate; then, right mandibular secondpremolar was
anesthetized using an IANB and long buc-cal nerve block injection
(Lidocaine 2% with epinephrine1 : 80000; Daroupakhsh, Tehran,
Iran). The tooth was gentlyextracted by forceps with no
intraoperative complications;subsequently, apical 3mm of the root
apex was resected andthe root end cavity was prepared and filled
with CEM cement(Figure 4).
Afterwards, the root surfaces were treated with tetracy-cline
for 30 seconds to enhance the periodontal ligamentcell attachment
[7]. Next, the extracted tooth was replantedin its original
position, and it was immobilized using asemirigid splint for 10
days (Figure 5). 4 × 400mg ibuprofen,0.2% chlorhexidine gluconate
mouth rinse, and 3 × 500mgamoxicillin daily for a week were
prescribed.
3. Clinicoradiographical Followup
Tooth’s sensitivity to percussion and mobility were exam-ined
every three months. We evaluated the percussion toneand compared it
with adjacent teeth. At 12 months afterintentional replantation, no
periodontal pocket was detectedand the tooth was completely
asymptomatic; it also had aslight degree of physiologic mobility.
Furthermore, periapicalradiolucency was noticeably reduced (Figure
6).
4. Discussion
When nonsurgical and surgical endodontic procedures havebeen
deemed impossible and the patient desires all possibleefforts be
made to avoid tooth extraction and implantreplacement, intentional
replantation could be considered asthe last treatment option
[8].
Extraction and replantation of the tooth has been per-formed to
manage several different problematic cases suchas vertically
fractured tooth [9], periodontally compromised
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Case Reports in Dentistry 3
Figure 4: After the tooth extraction, apical 3mm of the root
apex was resected and the root end cavity was prepared and filled
with CEMcement.
hopeless tooth [10], calcified tooth [5], and iatrogenic
perfo-ration [11].
As described before, surgical endodontic treatment formandibular
premolars may lead to damaging adjacent vitalstructure such as the
contents of mental foramen [12]; thus,before treatment planning,
the risk for developing mentalparesthesia after apicoectomy was
seriously considered.
In addition, there was an iatrogenic perforation on thedistal
root surface 1mm below the alveolar crest. The shortdistance
between the perforation area and the alveolar crestwas a cause for
concern, because there was danger ofoccurring bone loss and forming
a periodontal pocket in thearea [13], but after root resection and
replantation the toothwas placed about 2mmmore apically than
before; in so doing,the distance between the perforation site and
the alveolarcrest was increased (Figure 7).
In order to seal the apex of the tooth number 29, its rootwas
resected and retrofilled with CEM cement. CEM cement
is a biocompatible biomaterial [14] which is demonstratedthat
has an acceptable sealing ability when it is used to seal theroot
end cavities [15] and furcal perforations [16]. Also, it hasbeen
shown that in comparison to mineral trioxide aggregate(MTA), CEM
cement’s apical plug has superior sealing ability[17]. Therefore,
in this case CEM cement was used to seal theperforation site and
root end cavity.
The presence of healthy cementum on the root surface isone of
the most important factors in prevention of ankylosis[18]. In order
to produce a root surface that is conductive tocellular adhesion
and growth, several solutions such as usingtetracycline, citric
acid, and ethylenediaminetetraacetic acid(EDTA) have been suggested
[19]. In addition, in the previousstudies [9, 20] tetracycline was
used to treat the subjectedteeth for thirty seconds just before the
replantation. On thebasis of these findings, in this case,
tetracycline was appliedto the root surfaces to enhance periodontal
ligament fiberattachment and prevent ankylosis.
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4 Case Reports in Dentistry
Figure 5: After replantation, the tooth was immobilized with
asemirigid splint for 10 days.
Figure 6: 12 months after intentional replantation,
periapicalradiolucency was noticeably reduced.
We evaluated the tooth’s mobility and percussion soundduring our
controls to detect the ankylosis; because we knowthat the initial
locations of ankylosis are usually on thelingual and/or labial
tooth surfaces [21, 22], and it has beendemonstrated that if an
ankylotic area is located in these partsof a tooth, it will not be
radiographically detectable [21].
After a year the right mandibular second premolar wasmobile
within normal limits, and the percussion tone was thesame as that
of the healthy adjacent tooth, but it is clear thatmonitoring this
tooth for a long period of time is favorable.
5. Conclusion
Intentional replantation of the necrotic calcified teeth couldbe
considered as an alternative to teeth extraction, especially
Figure 7: The distance between perforation site and the
alveolarcrest that has been shown with the red brackets was
increased afterroot resection and tooth replantation.
for the single-rooted teeth andwhen nonsurgical and
surgicalendodontic procedures seem impossible.
Conflict of Interests
The authors declare that there is no conflict of
interestsregarding the publication of this paper.
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